Provider Demographics
NPI:1508964347
Name:JACKSON, KATHLEEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7702 W THURSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218
Mailing Address - Country:US
Mailing Address - Phone:414-438-6534
Mailing Address - Fax:414-438-6534
Practice Address - Street 1:7702 W THURSTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:414-438-6534
Practice Address - Fax:414-438-6534
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI84084030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39966400Medicaid